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Appendix Vill <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation 0 Repair Z 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID ' Test Date <br /> 10933741 9111125 <br /> Facility Name <br /> Orilandos Market <br /> Facility Address city ZIP Code <br /> 2226 Jackson Ave Escalon 95320 <br /> 2. SERVICE TECH NICIAN INFORMAT]ON <br /> Company Performing the Test Phone <br /> JP Petroleum Service 916-37 ZS93 <br /> Mailing Address <br /> 3065 Asante Lane We.st Sacramento- a 3569_1 <br /> Service Technician Performing Test <br /> Join PIjumala <br /> ontractorlTank Tester License Number <br /> 811471 <br /> ICC Number - ICC Expiration Date <br /> 6252405 2/2026 <br /> 3. TRAINING ARID CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW 812026 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> Hydrostatic Spill Buckets <br /> b. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that each spill container was tested in accordance with California Cade of <br /> Regulations, trifle 23, division 3, chapter 16, section 3637.1; that required supporting <br /> documentation is attached; and all information contained herein is accurate. 1 understand <br /> that test procedures shafl be made available argon request by the goveming authority. <br /> Service Technician Signature Date Total # of Pages <br /> = California Environmental Reporting System, ID = Identification. ICC = International Code <br /> Council <br /> Page 1 of <br />